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Internal QA Auditor - Hybrid

Date:  Feb 26, 2023

Any city, OH, US, 99999

Req ID:  15422

Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development. 



Claims Quality Auditor audits claims for manual and automated processed accuracy, coding accuracy, benefit payment, contract interpretation, and compliance with state regulations and internal policies and procedures. Selects claims through random processes and/or other criteria. Being a Claims Quality Auditor, make recommendations to improve quality, workflow processes, policies, procedures, and system configuration. The Claims Quality Auditor will report to the Claim Manager. The Claims Quality Auditor gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work.

Your role in our mission

  • Conduct quality audits of manual and automatically processed claims, pre, and post-payments, utilizing appropriate sources of information, including eligibility, enrollment, state contracts, provider and facility contracts, and state and health plan billing manuals.
  • Remain current on federal and state payment policies and methodologies and company policies and procedures; monitor public sources to identify, track, and communicate changes. Develops implementation plans for the introduction, adoption, or modification of payment policies based on legislative or regulatory actions or internal decision-making. Monitor state websites and contract changes for impact on claim payments and update audit criteria as necessary. Respond to inquiries from Ohio State Medicaid and internal departments as assigned.
  • Analyze errors and determine root causes for the appropriate classification.
  • Provide written documentation regarding audit observations and recommend Payee outreach on claim submission errors.
  • Analyze and review responses to audit observations and facilitate corrective action plans.

What we're looking for

  • Preferred 2+ years of medical claims processing or auditing experience
  • Proficient in MS Office.
  • Knowledge of Medicare and Medicaid reimbursement rules
  • Required understanding of and experience in medical claims payment configuration processes/systems.
  • Strong problem-solving capabilities. Ability to perform root cause analysis when determining areas of opportunity to improve results.

What you should expect in this role





The pay range for this position is $47,000 - $67,000 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.


We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.


Gainwell Technologies is committed to a diverse, equitable, and inclusive workplace. We are proud to be an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. We celebrate diversity and are dedicated to creating an inclusive environment for all employees.

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